Enhancing Safety: the Challenge of Foresight - ESReDA Project Group Foresight in Safety

This Deliverable is the result of a joint effort by experts, working in the fields of risks management, accident analysis, learning from experience and safety management. They come from 10 countries mainly from Europe and also from USA and Australia. Their expertise covers several industrial sectors. They attempted to provide useful information, both from a theoretical and a practical point of views, about "Foresight in Safety". Safety is still an ongoing issue for which a number of subjects remain under debate (e.g. is goal of safety to ensure that 'as few things as possible go wrong' or to ensure that ‘as many things as possible go right’?). Anyway, we can assume that safety is to act in a way for both the process continues to be run right and that errors and failures to not lead to a major accident. Even if "foresight in safety" is the implicit underlying goal of every practitioner in safety, the outlines of its domain remain blurred and the relevant topics associated with it have never been clearly defined. A humble ambition of this Deliverable is to display some aspects of "foresight in safety" according to the current state of practices and scientific knowledge.JRC.G.10-Knowledge for Nuclear Security and Safet

Modern accident investigation - Four major challenges

Nowadays, 'investigation' is a very commonly advocated approach and consequently is becoming an umbrella concept. 'Investigation' includes many types of approaches on different system levels. Originating from transport accidents and crime scenes, 'investigation' ranges from genocide, natural disasters, via discrimination, health care to crime fighting, economic fraud and ethical questions in engineering and management. In such a changing operating environment and widespread applications, accident investigation must reassess its distinctive role, purposes and operating conditions. It must clarify and communicate its specific aims and functions and performance to such an extent that it maintains its credibility, capability and quality in the eye of professionals, politicians as well as the public. Based on an assessment of the past performance of leading investigation agencies, practical experiences during major ad hoc accident investigations and changes in the operating environment, a SWOT analysis identified several issues as internal and external challenges in the future conduct of major investigations. Finally, the article proposes several priorities, challenging each stakeholder and expert in the investigation community to contribute from its own perspective to improve accident investigation theory and practices. (C) 2011 Elsevier Ltd. All rights reserved

Public safety investigations-A new evolutionary step in safety enhancement?

A historical overview highlights the evolutionary nature of developments in accident investigations in the transport industry. Based on a series of major events outside transportation, the concept of accident investigations has broadened to other domains and to a widening of the scope of the investigation. Consequently, existing investigation boards are forced to adapt their mandates, missions and methods. With the introduction of social risk perception and application of the concept of safety investigation in the public sector, a change of focus towards the aftermath and non-technical issues of a more generic nature emerges. This expansion has also gained the interest of social sciences and public governance, generating new underlying models and theories on risk and responsibility. The evolutionary development of safety investigations is demonstrated by the various organisational forms which shaped accident investigations in different countries. Underneath these organisational differences, a need for a common methodology and a reflection oil fundamental notions is discussed. In particular differences among human operator models, the allocation of responsibilities in design concepts and methodological issue are elaborated. The needs and opportunities for a transition from accident prevention towards systems change are indicated. At present, the situation is ambiguous. Ail encompassing inventory can only provide a general oversight over emerging trends and lacks analytic rigor on specific topics. The societal dimensions, institutional changes at the level of governance and control and the powers that advocate or challenge investigations are not yet fully described. Therefore, in the conclusions a small number of critical challenges and threats are identified that should be open to scrutiny in order to facilitate a new, evolutionary step in safety enhancement. (C) 2009 Elsevier Ltd. All rights reserved

Public safety investigations - a new evolutionary step in safety enhancement?

Over the past years, natural catastrophes have disrupted society: the tsunami in December 2004, hurricane Katrina in the Gulf of Mexico, the earthquakes in Pakistan in 2005, causing massive material destruction and human suffering. In addition, technological accidents in transport, energy and process industry undermine the public faith in risk management, while the uncontrolled spreading of diseases and viruses put high demands on medical and emergency responses and public governance decision making. The use of experiences and lessons learned from such major events is considered a valuable tool in understanding causal mechanisms and in taking appropriate measures to prevent recurrence, reduction of the consequences and restoring public faith in governance and decision making. Started in the transportation industry in the early sixties of the previous century, the phenomenon of independent public safety investigations has now been recognized as a valuable tool for safety enhancement in other industrial sectors and areas of public governance. At an international level, the EU has issued several Guidelines for their mandatory application in high-tech sectors, putting demands on the Member States to install independent governmental agencies, to harmonize concepts and investigation procedures and to feed back their findings and recommendations in EU policy making. Apart from their substantive contribution to improving knowledge about causal phenomena and accident prevention, safety investigations have been advocated as high potential tools in restoring public faith after a major event and in arbitration in societal dissensus about risk acceptability and risk perception. Safety investigations focus on enhancing the systems safety performance in contrast to accident investigations, which have their focus on preventing recurrence of accidents and incidents. Conducting safety investigations have been characterized as a Citizens' Right and Society's Duty. Such a recognition however, also sets a series of challenges for a wider application of this investigation tool outside its original technical domain, expanding the concept to all phases of the accident sequence, before, during and after the event, and to higher levels of the socio-technical systems in which the events are embedded and risk debates require expertise in supporting risk ion making. This contribution is primarily based on observations of trends and patterns as they emerge in society, and by the lack of scientific literature, assessed by expert judgment. It describes and analyses several trends and types of investigations that have developed over the past decade, focusing on their strengths and weaknesses, dilemmas, potential for prevention and ability to change systems safety characteristics. It identifies critical areas of attention for further development focusing on substantive issues as well as specific sectorial and national constraints in their implementation

Accident investigation practices in Europe—main responses from a recent study of accidents in industry and transport

Europe has during recent years been shocked by disasters from natural events and technical breakdowns. The consequences have been comprehensive, measured by lost lives, injuries, and material and environmental damage. ESReDA wanted in 2000 – by setting up a special expert group on accident investigation – to clarify the state of art of accident investigation practices and to map the use of thoroughly accident investigation in order to learn lessons from past disasters and prevent new ones. The scope was to cover three sectors in the society: transport, production processes and storage of hazardous materials, and energy production. The main method used was a questionnaire, which was sent in 2001 to about 150 organisations. About 50 replies were analysed. The replies showed great variations but also similarities, among others in definition of accident and incident, the objectives of the investigation team, criteria used to start an investigation, the status of the investigation organisation, the flow of information, the composition of the investigation team, and the use of internal or international procedures or rules. Several methods (in total 14 different methods were mentioned) were used for carrying out accident /incident investigations. Most of the respondents were willing to co-operate in one or another way with ESReDA. Although there are important biases in the material, the results from questionnaire are important inputs to the future work of ESReDA Expert group in this field. 3 safety approaches have been identified

Results and lessons learned from the ESReDA's Accident Investigation Working Group: Introducing article to "Safety Science" special issue on "Industrial Events Investigation"

The European Safety Reliability and Data Association (ESReDA) established in year 2000, a Working Group on Accident Investigation (WGAI) that ended in the year 2008. With the objective of improving the quality of accident investigation and as a consequence the learning from experience process and the safety performance, the working group tasked itself at two levels: the first one, at a societal, institutional and legal level, on the public accident investigation issue; the second one, at a methodological and organisational level, on the conduct of accident investigation. The underlying process that the working group followed was firstly to establish a state of the art of accident investigation practices and secondly to foster exchanges and dissemination of best practices through issuing guidelines, reports and by organising scientific seminars. This article summarises the working group achievements made visible in editing three reports and organising two ESReDA seminars in the area of safety investigation of accidents. The article presents a synthesis of the approach and main results, the lessons learned, some dilemmas and conflicts, several future challenges, recommendations and suggestions for action to the main stakeholders involving European and member state authorities, industrials, research centres and universities, and professionals of the rising accident investigation community.JRC.F.3-Energy securit

Results and lessons learned from the ESReDA's Accident Investigation Working Group : Introducing article to "Safety Science" special issue on "Industrial Events Investigation"

International audienceThe European Safety Reliability and Data Association (ESReDA) established in year 2000, a Working Group on Accident Investigation (WGAI) that ended in the year 2008. With the objective of improving the quality of accident investigation and as a consequence the learning from experience process and the safety performance, the working group tasked itself at two levels: the first one, at a societal, institutional and legal level, on the public accident investigation issue; the second one, at a methodological and organisational level, on the conduct of accident investigation. The underlying process that the working group followed was firstly to establish a state of the art of accident investigation practices and secondly to foster exchanges and dissemination of best practices through issuing guidelines, reports and by organising scientific seminars. This article summarises the working group achievements made visible in editing three reports and organising two ESReDA seminars in the area of safety investigation of accidents. The article presents a synthesis of the approach and main results, the lessons learned, some dilemmas and conflicts, several future challenges, recommendations and suggestions for action to the main stakeholders involving European and member state authorities, industrials, research centres and universities, and professionals of the rising accident investigation communit

Guidelines for Safety Investigations of Accidents

These guidelines have been prepared for investigators, investigation managers, people who order investigations, responsible persons who will have to learn from the event, victims and researchers. These guidelines provide a minimum, current and recognised cross-sectorial best practices oversight to conduct investigations related to industrial, technological and organisational events. These guidelines give practical and theoretical advices related to the different stages of such investigations. In-depth analysis of accidents, incidents and crises clearly showed that any event is generated by direct or immediate causes (technical failure and/or ¿ "human error"). Nevertheless their occurrence and/or their development is considered to be induced, facilitated or accelerated by underlying organisational conditions (complex factors) found in socio-technical system and organisational networks. It implies to deal with different natures of causalities: mechanistic met in technical installations and more complex met in human and social systems. Addressing those causalities requires various competencies (with disciplines from exact sciences, to engineering and social sciences) to investigate and to learn from an accident. Accident investigation can be performed for various reasons and objectives. They depend on the stakeholders (many types among companies, authorities, or public parties) and their perspectives. Several investigations could often be managed simultaneously (e.g. judicial, technical,¿) and it may lead to interest and operational conflicts such as the access to the accident scene and witnesses, the collection of the facts, the preservation of evidence, the findings, the communication of findings,¿ Corporate, political, cultural and societal requirements will shape the context in which the investigation is conducted. This should be cleared and stated when defining the mandate of the investigation. Despite all this variety of contexts, investigation obeys to general principles (protocols, coordination, competence, data and evidence, reporting, follow-up of lessons learned and communication) and to process phases (defining terms of reference, appointing team, collecting data, hypotheses generation, analysis, findings and recommendations). Connection between phases is not a linear process but rather an iterative one. Any investigator gets skills and know-how, so accident investigation is influenced by a priori knowledge or initial models. Specific methodologies have been developed to facilitate some investigation tasks. They use different logical constructions, different underlying models, and address different levels of phenomena with various perspectives (what happened, why it happened and what is recommended to prevent its repetition). Organisations should prepare their protocols and train their investigators before the event occurs in order to be ready to undertake the investigation in an effective way. These guidelines aim to support those processes. To communicate during and after the investigation process is an important issue. Aim is to provide stakeholders with findings through a report or other supports in order to initiate and facilitate the learning process. Many barriers to learn lessons can be faced by organisations. Turning findings into recommendations (corrective measures) is a specific task that requires specific knowledge of the organisational network and the socio-technical system behaviour. The corrective measures can be challenged by reality and a specific follow-up should be put in place. Finally, some future challenges that would have to be addressed by the investigation and safety management communities conclude the present guidelines.JRC.F.3-Energy securit